| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,203 |
2,197 |
$171K |
| D1120 |
Prophylaxis - child |
1,918 |
1,916 |
$117K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
982 |
506 |
$59K |
| D0330 |
Panoramic radiographic image |
266 |
266 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
217 |
130 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
282 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
126 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
3,566 |
3,559 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
14 |
$561.03 |
| D0274 |
Bitewings - four radiographic images |
997 |
994 |
$84.29 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
290 |
248 |
$24.46 |
| D0272 |
Bitewings - two radiographic images |
982 |
980 |
$0.00 |
| D1351 |
Sealant - per tooth |
101 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
86 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
3,115 |
3,110 |
$-196.58 |